Wednesday, August 22, 2007

The rough thing about attending a posh CME in a serene location is that one tends to forget the reality of everyday work life in the ghetto. In case you had forgotten, allow newFNP to refresh your memory: it sucks.

NewFNP is right back in the thick of it: leaving an hour late, attempting to correct the fact that she had seven patients scheduled in the three o'clock hour today and dodging bullets fired by the ever-critical and sorely lacking in introspection OB-GYN. Hey sister, when you point one finger at newFNP, there are four pointing at yourself, you ho-bag.

NewFNP returned from her conference ready to take on the world. Well, the world has dealt newFNP a real shit-storm. So much so that newFNP has begun to question whether she really is doing well for her patients.

The OB/GYN is quick to point out the cazillions of flaws she sees in the care that newFNP and the other prenatal providers have delivered, yet this provider sees an average of 10 patients per clinical day. She is not at all hesitant to allow other providers to see the remaining patients on her schedule as she delves into every detail of her patients' care. NewFNP truly makes every effort to address all pertinent aspects of medical care as well as engaging the patient about social issues, but newFNP has a 30-patient schedule and, therefore, misses things sometimes. Does this make newFNP a bad, incompetent or inadequate provider? Is the OB/GYN right in just giving a big "F-you" to the rest of us while she assesses for every fucking hangnail that may trigger preterm labor, birth anomalies and the omnipresent threat of legal action?

Another new physician pointed out that newFNP's clinic is "killing" our patients because we cannot start diabetic patients on insulin if their A1C's are over 8.5 or 9. The reason newFNP is unable to do so is that a very small number of patients can afford blood glucose monitoring supplies. The new provider didn't mean it as a judgment, but rather as a statement of fact. However, newFNP feels acutely aware that she is between the proverbial rock and hard place. NewFNP can either slowly kill them with the ravages of hyperglycemia or quickly kill them with the rapid action of hypoglycemia. Talk about choosing between the bat and the belt! What a fucked up world we live in. Perhaps there is a program that would supply all of newFNP'sDM patients with testing supplies and syringes, but newFNP doesn't have even five minutes in her day to research this.

NewFNP is uncertain what to do. She is at her two-year anniversary at her clinic. NewFNPis community health and had planned on staying at this clinic indefinitely. But how in the fuck can newFNP put up with all of this?

On the positive side, everyone loves newFNP's new hair-do - even the fashionable gay guy so newFNPknows that she is looking hot! Watch out!

Saturday, August 18, 2007

New FNP learned quite a bit while she was at her CME. However, the most striking thing that newFNP learned is that her patients will likely not benefit from a fucking shred of what they should be receiving.

For instance, the lovely and brilliant physician who lead the Obesity 2007 chat couldn't stress enough the importance of a nutritionist. Yes, indeed. However, let's just say that hiring a nutritionist is not on newFNP's clinic's short-list. Very low calorie diet? In newFNP's clinic, we call that 'food insecurity' as no one ever self-restricts to 800 kcal/day. NewFNP was thrilled to have it made public that a BMI of 26 has a positive effect on mortality. Ah, NHANES, God bless ya! NewFNP already knows that a little extra cushion is her natural set point, but she is stoked to know that science is getting on board with the voluptuous lady. Interestingly, this speaker did spend a fair amount of time on discussion of how fitness truly helps in preventing mortality. If your BMI is 31 but you are a walking-fool (45 minutes/day while talking), you're actually not in that bad of shape. However, if the only exercise you go is extending your left arm though your auto-roll-down car window to reach for your double bacon piece of shit burger, then - yes - you are on the train track to an MI.

And the fertility lecture. Fascinating, especially when newFNP has had two thirty-something friends struggle with it. Practical in newFNP's urban free health clinic? Uh, no. Interesting to learn that laying supine with the knees up for twenty post-coital minutes is advised if attempting pregnancy. NewFNP suspects that adopting such a position might lead to a 'round two' which goes against the tenet of QOD action for best baby-making.

NewFNP learned a lot about bisphosphonates. However, newFNP has succeeded in getting a single patient a bone mineral density scan. NewFNP would love to help the ladies spare the hip fracture - hell, who wouldn't! But newFNP is reluctant to just start adding Actonel to the water supply.

One great overall experience that newFNP had was to see that her practice was already mirroring a lot of what these experts were recommending. Hallelujah! And she is doing procedures which many of the physicians in attendance don't do, such as IUC (new phrase - apparently IUD is out of vogue) insertions. Why would anyone want to do less? Sure, newFNP would want to do fewer prostate exams but newFNP wishes that she could, for example, be doing biopsies for her patients. Because frankly, if newFNP's clinic isn't providing the care, it's unlikely that newFNP's patients will receive specialist care.

There are, however, things that newFNP would like to do more of, such as starting patients on insulin. However, newFNP's patients don't have glucose monitors so one shan't prescribe a hypoglycemic without appropriate monitoring! This conference recommended starting patients on insulin when they have an A1C greater than 8.5. Holy fuck - newFNP rarely sees a patient with an A1C that low, at least when they initiate care with us. A1C of 15.4, sure. Of 17.2 - rarely but not unheard of. When newFNP gets an A1c into single digits on oral hypoglycemics, she is quite thankful.

Mostly what newFNP learned is that she loves to take bike-rides through one of her state's most beautiful areas, amongst trees and rivers and a huge, glorious lake. NewFNP learned that perhaps her huge urban area is not where she will be for the rest of her life, that perhaps she will need a mid-point between the luxuries of urban life and the natural beauty which is too few and far between in her city.

Tuesday, August 14, 2007

Clinical practice, however, is not so tidy. Especially family practice. Being a generalist is tough. In the eyes of the patient, one is expected to know it all, be it funky dermatological lesion, West Nile Virus or lumbago. However, in clinical practice, patients give horrible histories and, in newFNP's practice, this issue is significantly exacerbated by the ole language issue. In clinical practice, newFNP doesn't have the luxury of having convenient multiple choice answers from which to choose her differential diagnoses.

NewFNP will, at some point, share some of the more illuminating information gleaned from the conference, but in the mean time, can she just say that she enjoyed so thoroughly her 12-mile scenic bike ride with BostonFNP and her younger sister RooSF? NewFNP is leading a life of leisure! Post-conference and gym yesterday, we all hit the pool where newFNP donned some very now Tom Ford sunglasses, slathered herself in SPF, and read The NewYorker. She topped her evening off with not one, but two margaritas and a crab tostada.

NewFNP loves her CME. It's not just all the leisure either. NewFNP feels inspired yet again to be an excellent clinician and is in touch with her inner nerd as she basks in the glow of the Power Point slides.

Ahhhh..... Continuing Medical Edu-vacation. Just what the nurse practitioner ordered!

Saturday, August 11, 2007

Does everyone remember when Aidan and Carrie broke up? At the end of the break-up episode, Carrie had her wild, curly mane and, at the opening of the next episode, it was transformed into a chic, short-ish curly-bob. New hair, new life.

NewFNP. New hair-do. Soon to be new apartment with new couch (thank the heavens for Crate & Barrel). Still with old job but without old boyfriend.

And, in the midst of it all, newFNP was actually thankful to have her crazy job, her NP student and her intellectual stimulation. How do people go through break-ups if they have some mindless job in which they can ruminate and sift through the remains of the relationship? It's not often that newFNP is thankful that she has nary a minute to re-apply lip gloss or take a sip of filtered water, but she has been very thankful for her hectic schedule this past month.

Even more so than that, newFNP has been thankful that her career actually means something to her patients.

This past week, newFNP had the pleasure of working with Dr. G. Dr. G. is newFNP's age and went to med school a mere block away from newFNP's nursing school. Yes, newFNP and Dr. G. have probably walked the same hospital floors but never knew each other until practicing community health on the other side of the country. Dr. G. mentioned to newFNP that one of the things -in a very long list, of course - that makes her a good provider is that she truly cares for her patients, that she listens, that she asks them questions about their lives. During this time of major personal change, it was nice to get that validation from a co-worker.

It was just as nice when a patient's fasting glucose dropped from the mid-300's to the low-mid 100's after newFNP stopped his oral hypoglycemics and started him on an all-insulin regimen. Most of newFNP's patient cannot afford glucometers and supplies, so newFNP hasn't had the opportunity to do this transition very often. Nonetheless, even though he is technically a Type 2 diabetic, newFNP believed that his pancreas had thrown in the towel. There isn't enough metformin in the world to help this guy out. Furthermore, this patient was an exception in that he had glucose monitoring supplies, so newFNP wrote out a detailed baseline NPH insulin regimen with instructions for regular insulin sliding-scale coverage. She was so proud of herself and her patient when his glucose started to stabilize.

Now, newFNP knows that this one day of control may be an anomaly. However, to get props from a co-worker and to achieve something akin to medical success constitutes one hell of a week for newFNP.

Just wait until those fuckers see newFNP's fierce new hair-do. They'll have to wait a week, though, because newFNP and BostonFNP are hitting up the vacation CME in a fun-filled resort town.

As BostonFNP's dad once told us, learning without laughter is like a day without sunshine. NewFNP cannot wait to have both at her Continuing Medical Edu-vacation.

Thursday, August 02, 2007

NewFNP's student finished her month at the clinic and claimed to learn a lot from newFNP. Ah, shaping young minds - what an inspiration. It helps when the student is brand new and literally everything is a learning experience.

All in all, newFNP was glad that her student got to see just how community health practice is.

For instance, one day newFNP asked her student to leave a half hour early so she would be spared the experience of observing newFNP rail on the manager for overbooking appointments at the end of the day. Certainly not community health's finest hour, but an integral part of newFNP's clinical experience.

Another day, newFNP was giving a little nutrition education to the parent of an obese three year old which included advising her to avoid giving her kid candy, to which this parent responded, "Oh, I don't give him candy - just lollipops." Bingo. When newFNP explained that lollipops are, in fact, a form of candy, the mother was astounded. "They are?," she asked, wide-eyed and as sincere as could be. You just can't pay for that kind of education. Truly, how many people with whom newFNP's student is in contact fail to grasp that a lollipop is candy? Are there some marketing geniuses at the super mercado who are selling lollipops in the produce section, convincing slow parents that a cherry-flavored lollipop is one in the quest for five fruits/veggies per day?

NewFNP had her patient doing paps, cleaning out cerumen, listening to hearts and lungs - whatever she could get her to do. NewFNP really loved doing the teaching, but realized that she was completely disorganized in the process. As newFNP's student has just finished her accelerated RN year and has yet to do her health assessment class, newFNP felt a little unsure as to how to help her along. At any rate, newFNP thinks that her student will be ahead of the pack when she starts her master's clinicals next year and that she herself will be better organized when the next student comes along.

And, for newFNP, it was really meaningful to help to support someone in their learning and in their development into an NP. So thanks to newFNP's alma mater and to her student for making an otherwise crappy July 2007 something meaningful.

This blog is for new NPs or NP students who want some real 411 on the life of a new practitioner. A new practitioner in a busy, understaffed, urban community health clinic in a major metropolitan area. Oh, and newFNP swears while writing and, sometimes, while working although she tries to keep those swears to herself. Consider yourself warned.